Diagnosis and treatment of gallbladder perforation

Early versus delayed laparoscopic cholecystectomy for gallbladder perforation

BACKGROUND

Gallbladder perforation occurs in 2% to 11% of patients with acute cholecystitis, with associated mortality estimated to be at 12% to 42%. Because of its low incidence, the data on management remain sparse. There is a lack of evidence to suggest whether early or delayed cholecystectomy is superior in the treatment of perforated cholecystitis. We hypothesize that an early definitive operation is associated with decreased total hospital length of stay (THLOS).

METHODS

Using the National Surgical Quality Improvement Program database from the American College of Surgery, we identified patients who underwent laparoscopic cholecystectomy for gallbladder perforation on an urgent or emergent basis from 2012 to 2021. We divided them into those who underwent early (<2 days from the date of admission to the date of operation) and delayed cholecystectomy (≥2 days from the date of admission to the date of operation). Our primary outcome was the THLOS. We created multivariate regression models to assess for the association of early versus delayed operation and THLOS.

RESULTS

The THLOS was found to be 2.94 days longer in the delayed group compared with the early group (p < 0.05). In those who did not present with sepsis on admission, the THLOS was noted to be 4.71 days longer in the delayed group compared with the early group (p < 0.05). Early versus delayed operation was not associated with a difference in the postoperative length of stay, 30-day postoperative complications, rate of readmission, and reoperation, regardless of preoperative sepsis status.

CONCLUSION

Early laparoscopic cholecystectomy for gallbladder perforation is associated with decreased THLOS, and there were no other differences in outcomes compared with delayed laparoscopic cholecystectomy. Patients with gallbladder perforation would likely benefit from an early operation within 2 days of admission.

LEVEL OF EVIDENCE

Therapeutic/Care management; Level IV.

Evaluation of bile acids and bilirubin in serum and abdominal fluid in dogs with abdominal effusion

OBJECTIVES

Determine the utility of abdominal fluid bile acids concentration to diagnose biliary tract rupture and the utility of abdominal fluid-to-serum bilirubin ratio as diagnostic tools in dogs.

MATERIALS AND METHODS

This was a prospective pilot study. Canine serum and abdominal fluid samples were collected and submitted for the determination of bilirubin and bile acids concentrations between 2020 and 2022. Samples were measured at the time of admission from dogs with acute onset of clinical signs and peritoneal fluid. A Mann-Whitney U test and ROC curves were used to compare serum and abdominal fluid bilirubin and bile acids concentration and fluid-to-serum bilirubin and bile acids ratio between patients with biliary tract rupture and non-biliary tract rupture.

RESULTS

Ninety-four cases were included, of which seven were diagnosed with biliary tract rupture. Median abdominal fluid bile acids concentration was significantly higher in dogs with biliary tract rupture than non-biliary tract rupture (P-value <0.001). Abdominal fluid bile acids concentration had a sensitivity of 100% and specificity of 99% for the diagnosis of biliary tract rupture. Fluid-to-serum bilirubin ratio was also analysed and no statistically significant difference was seen between groups (P-value 0.925).

CLINICAL SIGNIFICANCE

Although the number of dogs with biliary tract rupture in this study population was small, abdominal fluid bile acids concentration may have a better accuracy than fluid-to-serum bilirubin ratio for the diagnosis of biliary tract rupture. The utility of fluid-to-serum bilirubin ratio for the diagnosis of biliary tract rupture, appears limited. Further studies with a larger number of biliary tract rupture cases are required to support these conclusions.

Gallbladder perforation causing local peritonitis in left upper abdomen: A case report

INTRODUCTION AND IMPORTANCE

Type 1 gallbladder perforation (GBP) in the free abdominal cavity causes pan-peritonitis, which is both rare and difficult to diagnose.

CASE PRESENTATION

An 80-year-old man presented to our hospital with acute left upper abdominal pain. Twenty days prior to presentation, he had been admitted for 12 days with coronavirus disease 2019 (COVID-19). The patient had mild cholecystitis and received conservative therapy for COVID-19. Upon readmission, his abdomen was flat and soft except for local peritonitis in the left upper abdomen. An emergency laparoscopy revealed a perforation in the ventral wall of the gallbladder neck discharging pus under the lateral lobe of the liver without a gastrointestinal perforation. Therefore, a laparoscopic cholecystectomy and intra-abdominal lavage were performed. Based on the clinical and pathological findings, the GBP was suspected to be a rupture of the abscess in the Rokitansky-Aschoff sinus observed on magnetic resonance imaging during the first admission.

DISCUSSION

In this case, acute cholecystitis was suppressed by conservative therapy, leaving adhesions of the surrounding tissue and viscus to the gallbladder fundus and body as well as an abscess in the wall of the neck. This was the cause of the GBP and resulted in local peritonitis within the left upper abdomen.

CONCLUSION

Type 1 GBP develops suddenly and cannot be predicted. In cases of acute cholecystitis once suppressed by conservative therapy and accompanied by cystic formation in the gallbladder wall, early cholecystectomy is recommended considering the risk of GBP.

Improving Diagnosis of Acute Cholecystitis with US: New Paradigms

Acute cholecystitis is an inflammatory condition of the gallbladder typically incited by mechanical obstruction. Accurate diagnosis of this common clinical condition is challenging due to variable imaging appearances as well as overlapping clinical manifestations with biliary colic, acute hepatitis, pancreatitis, and cholangiopathies. In acute cholecystitis, increased dilatation and high intraluminal pressures lead to gallbladder inflammation and may progress to gangrenous changes, focal wall necrosis, and subsequent perforation. In acute calculous cholecystitis, gallstones are the cause of obstruction and are often impacted in the gallbladder neck or cystic duct, leading to gallbladder inflammation. In acalculous cholecystitis, patients are typically critically ill, often with hypotensive episodes and prolonged gallbladder stasis, which lead to obstruction, gallbladder ischemia, and inflammation. Helpful sonographic findings of acute cholecystitis include a dilated gallbladder; increased intraluminal pressures in the gallbladder, resulting in a bulging fundus (tensile fundus sign); intraluminal sludge in the setting of right upper quadrant pain; wall hyperemia, which may be quantified by elevated cystic artery velocities or hepatic artery velocities; mucosal ischemic changes, characterized by loss of mucosal echogenicity; pericholecystic inflammation, characterized by hyperechoic pericholecystic fat; and mucosal discontinuity. Extruded complex fluid next to a wall defect is definitive for gallbladder wall perforation, and further evaluation with CT or MRI allows evaluation of the full extent of perforation and other potential complications. The sonographic Murphy sign, while helpful if positive, is relatively insensitive for accurate diagnosis of acute cholecystitis. Thus, overreliance on the sonographic Murphy sign results in surprisingly low diagnostic accuracy in practice.

Formation and rupture of liver hematomas caused by intrahepatic gallbladder perforation: A case report and review of literature

BACKGROUND

Gallbladder perforation is a serious complication of acute cholecystitis. Such perforation is a rare but life-threatening situation that can lead to the formation and rupture of liver hematomas. Here, we report a case of a ruptured intrahepatic hematoma caused by intrahepatic gallbladder perforation, and we present a literature review.

CASE SUMMARY

A 70-year-old male was admitted to the hospital with a complaint of right upper quadrant abdominal pain, flustering and dizziness. The preoperative diagnosis was a ruptured malignant liver tumor, and the patient's medical images and increased level of carbohydrate antigen-199 suggested that the gallbladder had been invaded. However, the tumor was proven to be a liver hematoma secondary to gallbladder perforation after surgery. The patient was discharged uneventfully on the fifteenth postoperative day.

CONCLUSION

Intrahepatic gallbladder perforation is difficult to diagnose preoperatively. Radiological examinations play a crucial role in the diagnosis but only for partial cases. Early diagnosis and appropriate surgery are key to managing this rare condition.

An Unusual Abscess Associated with Gallbladder Perforation Successfully Treated with Percutaneous Transhepatic Gallbladder Drainage and Endoscopic Ultrasound-guided Abscess Drainage

Abscesses associated with gallbladder perforation are often confined to the peri-gallbladder region. We herein report a rare case of gallbladder perforation in which the abscess cavity extended into the left upper quadrant. A 79-year-old woman developed gallbladder perforation secondary to acalculous cholecystitis. Computed tomography revealed fluid collection extending from the peri-gallbladder to the dorsal left hepatic lobe in contact with the stomach. We successfully treated percutaneous transhepatic gallbladder drainage and simultaneous endoscopic ultrasound-guided transgastric internal and external abscess drainage. This minimally invasive approach is considered safe and feasible for managing such a rare case.

Massive gastropathy due to gallstone obstruction of the duodenum (Bourveret syndrome)

Gallstones are common in the general population and are often asymptomatic, but they can also cause complications such as cholecystitis and pancreatitis. In rare instances, they can lead to the formation of a cholecystoduodenal fistula and gallstone ileus. Gastric dilatation and distension following gallstone ileus are extremely uncommon and have rarely been reported in the literature. We report a fatal case of massive gastropathy as a result of Bouveret syndrome secondary to gallstone obstruction.

Cholecystoappendiceal fistula associated with xanthogranulomatous cholecystitis

Xanthogranulomatous cholecystitis is a rare chronic inflammatory disease of the gallbladder associated with complications such as perforation, dense adhesions and fistulation. We present a case of a female patient in her 20s who presented with three episodes of recurrent cholecystitis over 3 months. Her medical history included an endoscopic retrograde cholangiopancreatography for obstructive jaundice due to choledocholithiasis. As there was no possibility of performing an urgent cholecystectomy during her initial admission, she was listed for an elective operation. Laparoscopic inspection revealed a pericholecystic mass involving the omentum, transverse colon, duodenum and liver and findings suspicious of a cholecystoappendiceal fistula. Laparoscopic cholecystectomy and appendicectomy were performed. Early index admission laparoscopic cholecystectomy should be performed in patients with acute cholecystitis to prevent higher grades of operative difficulty and associated complications. This case presentation-cholecystoappendiceal fistula associated with xanthogranulomatous cholecystitis-emphasises the necessity of complying with national guidelines in managing acute calculous cholecystitis.

A Case Report of Sepsis Secondary to Perforated Cholecystitis in the Presence of Severe Aortic Stenosis: Diagnosis and Management

Gallbladder perforation is a rare complication of acute cholecystitis that is associated with significant morbidity and mortality. Many cases of gallbladder perforation are not diagnosed until surgery, as the physical symptoms closely mimic acute cholecystitis. Gallbladder perforation is most common among older males with associated comorbidities, and preoperative assessment of comorbidities, particularly cardiac, is critical to determine the appropriate clinical course. We report a case of a 77-year-old male who presented initially with low blood pressure and right upper quadrant pain (RUQ) after not feeling well for five days. CT of the abdomen/pelvis with IV contrast demonstrated acute perforated cholecystitis, and general surgery was consulted for a cholecystectomy. Due to the patient's past medical history of severe aortic stenosis (AS), cholecystectomy was deferred and a cholecystostomy tube was placed by interventional radiology. This report aims to provide an example of a case of perforated cholecystitis with sepsis and how it can be diagnosed and managed non-surgically in the presence of pre-existing severe AS.

Gallbladder perforation in acute acalculous vs. calculous cholecystitis: a retrospective comparative cohort study with 10-year single-center experience

BACKGROUND

Gallstones are a well-known risk factor for acute cholecystitis. However, their role as a risk factor for gallbladder perforation (GBP) remains unclear. Therefore, this study aimed to determine the effect of gallstones on the development of GBP.

MATERIALS AND METHODS

This large-scale retrospective cohort study enroled consecutive patients who underwent cholecystectomy for acute cholecystitis. The primary endpoint was the role of gallstones as a risk factor for developing GBP. Secondary endpoints included the clinical characteristics of GBP, other risk factors for GBP, differences in clinical outcomes between patients with acalculous cholecystitis (AC) and calculous cholecystitis (CC), and the influence of cholecystectomy timing.

RESULTS

A total of 4497 patients were included in this study. The incidence of GBP was significantly higher in the AC group compared to the CC group (5.6% vs. 1.0%, P <0.001). However, there were no differences in ICU admission and hospital stay durations. The incidence of overall complications was significantly higher in the AC group than in the CC group (2.2% vs. 1.0%, P <0.001). Patients with AC had a higher risk of developing GBP than those with CC (odds ratio, 5.00; 95% CI, 2.94-8.33). In addition, older age (≥60 years), male sex, comorbidities, poor performance status, and concomitant acute cholangitis were associated with the development of GBP. Furthermore, the incidence of GBP was significantly higher in the delayed cholecystectomy group than in the early cholecystectomy group (2.0% vs. 0.9%, P <0.001).

CONCLUSIONS

AC is a significant risk factor for GBP. Furthermore, early cholecystectomy can significantly reduce GBP-related morbidity and mortality.

Traveling gallstones: review of MR imaging and surgical pathology features of gallstone disease and its complications in the gallbladder and beyond

Gallstone-related disease comprises a spectrum of conditions resulting from biliary stone formation, leading to obstruction and inflammatory complications. These can significantly impact patient quality of life and carry high morbidity if not accurately detected. Appropriate imaging is essential for evaluating the extent of gallstone disease and assuring appropriate clinical management. Magnetic Resonance Imaging (MRI) techniques (including Magnetic Resonance Cholangiopancreatography (MRCP) are increasingly used for diagnosis of gallstone disease and its complications and provide high contrast resolution and facilitate tissue-level assessment of gallstone disease processes. In this review we seek to delve deep into the spectrum of MR imaging in diagnose of gallstone-related disease within the gallbladder and complications related to migration of the gallstones to the gall bladder neck or cystic duct, common hepatic duct or bile duct (choledocholithiasis) and beyond, including gallstone pancreatitis, gallstone ileus, Bouveret syndrome, and dropped gallstones, by offering key examples from our practice. Furthermore, we will specifically highlight the crucial role of MRI and MRCP for enhancing diagnostic accuracy and improving patient outcomes in gallstone-related disease and showcase relevant surgical pathology specimens of various gallstone related complications.

Delayed duodenal/gastric fistula resulting in persistent perihepatic abscesses as a late complication of laparoscopic cholecystectomy

Since the early 1990's, laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic gallbladder disease. Although the incidence of postoperative complications is generally lower with this approach, gallbladder perforation represents a serious risk that is among the most common complications of laparoscopic cholecystectomy. The sequalae that can follow iatrogenic perforation have not been well documented and only a few case reports exist in the current literature. In this paper we discuss two case reports of delayed perihepatic abscesses following prior laparoscopic cholecystectomy, ultimately resulting in fistulous tracts. The course of the disease is discussed along with the diagnostic workup and eventual successful management of the aforementioned complications. Treating enteric fistulae requires a systematic approach and is carried out in phases. Enteric fistula formation following laparoscopic cholecystectomy is a rare complication of retained gallstones that can present months to years following the index operation. Significant care should be taken to avoid perforation and all efforts should be made to retrieve stones if spillage occurs.

Large biloma as the initial presentation of gallbladder perforation: a case report and literature review

Biloma is an encapsulated intra or extra-hepatic collection of bile after biliary tree trauma. Post-procedural and traumatic biliary damage are the most common etiologic causes. Gallbladder perforation due to acute cholecystitis rarely presents with biloma occurrence. We present a case of large extrahepatic biloma formation as a consequence of a perforated gallbladder.

Severe acute cholecystitis successfully treated with endoscopic nasobiliary drainage tube insertion: A case report

In this report, we present a case of a patient with bile peritonitis caused by gallbladder perforation associated with acute cholecystitis, which required intensive postoperative care. The patient was a woman in her 40s who presented with abdominal pain. Upon examination, she was diagnosed as having acute cholecystitis and bile peritonitis caused by gallbladder perforation. Subsequently, a partial cholecystectomy, omental pack, and drainage were performed. Initially, her bile duct enzyme levels improved; however, they subsequently increased again. An endoscopic nasobiliary drainage tube was inserted, and thereafter, a decrease in inflammatory response and bile duct enzyme levels was observed. During the course of treatment, respiratory failure and renal impairment occurred, necessitating mechanical ventilation management and continuous hemodiafiltration. In patients with severe acute cholecystitis, in addition to treating the underlying condition, it is crucial to perform procedures perioperatively, in anticipation of the development of additional organ dysfunctions postoperatively.

Spontaneous gallbladder perforation in a man with gallstone disease without known anamnesis of cholecystitis: Case report

INTRODUCTION

Spontaneous gallbladder perforation is a rare complication of gallstone disease. It causes acute peritonitis with potentially fatal outcome.

CASE PRESENTATION

We present a case of spontaneous gallbladder perforation with challenging diagnosis.

DISCUSSION

The diagnosis of gallbladder perforation should be considered in elderly patients presenting to the surgical emergency department with symptoms and signs of peritonitis even in the absence of pre-existing gallbladder disease. Spontaneous gallbladder perforation is a rare and potentially fatal diagnosis. In most reported cases, perforation occurred due to predisposing factors like acute cholecystitis, trauma or obstruction. In spite of rarity, spontaneous gallbladder perforation should be considered as differential diagnosis on examination of patients with sudden abdominal pain especially in cases of known cholecystolithiasis. Our patient had type 1 perforation according to Niemeier classification, the type associated with the highest mortality rate. The type of perforations has been reported as being difficult to recognize preoperatively, as with our patient with two inconclusive CT scans. This was due to the absence of classical symptoms of gallbladder perforation. CT is the modality of choice when gallbladder perforation is suspected.

CONCLUSION

We believe the reason for the spontaneous gallbladder perforation in the presented case was the presence of cholecystolithiasis. We acknowledge the importance of considering this diagnosis also in patients without previous signs of cholecystitis.

Gallbladder perforation with fistulous communication

BACKGROUND

The management of gallbladder perforation (GBP) with fistulous communication (Neimeier type I) is controversial.

AIM

To recommend management options for GBP with fistulous communication.

METHODS

A systematic review of studies describing the management of Neimeier type I GBP was performed according to the PRISMA guidelines. The search strategy was conducted in Scopus, Web of Science, MEDLINE, and EMBASE (May 2022). Data extraction was obtained for patient characteristics, type of intervention, days of hospitalization (DoH), complications, and site of fistulous communication.

RESULTS

A total of 54 patients (61% female) from case reports, series, and cohorts were included. The most frequent fistulous communication occurred in the abdominal wall. Patients from case reports/series had a similar proportion of complications between open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) (28.6 vs 12.5; P = 0.569). Mortality was higher in OC (14.3 vs 0.0; P = 0.467) but this proportion was given by only one patient. DoH were higher in OC (mean 26.3 d vs 6.6 d). There was no clear association between higher rates of complications of a given intervention in cohorts, and no mortality was observed.

CONCLUSION

Surgeons must evaluate the advantages and disadvantages of the therapeutic options. OC and LC are adequate options for the surgical management of GBP, with no significant differences.

Gallstone and Gallbladder Disease: Biliary Tract and Cholangiopathies

Cholestatic liver diseases are named primarily due to the blockage of bile flow and buildup of bile acids in the liver. Cholestasis can occur in cholangiopathies, fatty liver diseases, and during COVID-19 infection. Most literature evaluates damage occurring to the intrahepatic biliary tree during cholestasis; however, there may be associations between liver damage and gallbladder damage. Gallbladder damage can manifest as acute or chronic inflammation, perforation, polyps, cancer, and most commonly gallstones. Considering the gallbladder is an extension of the intrahepatic biliary network, and both tissues are lined by biliary epithelial cells that share common mechanisms and properties, it is worth further evaluation to understand the association between bile duct and gallbladder damage. In this comprehensive article, we discuss background information of the biliary tree and gallbladder, from function, damage, and therapeutic approaches. We then discuss published findings that identify gallbladder disorders in various liver diseases. Lastly, we provide the clinical aspect of gallbladder disorders in liver diseases and ways to enhance diagnostic and therapeutic approaches for congruent diagnosis. © 2023 American Physiological Society. Compr Physiol 13:4909-4943, 2023.

Giant Gallstone With Gallbladder Perforation and Hepatic Abscess in an Asian Patient

Giant gallstone with a secondary hepatic abscess is a very rare phenomenon. We recently treated a patient with a giant gallbladder (GB) stone of size 11.5 cm with a hepatic abscess who presented with features of an acute abdomen. This was subsequently managed with an open subtotal cholecystectomy and concomitant hepatic abscess drainage. To the best of our knowledge and after a thorough literature search, this is one of the largest reported gall bladder (GB) stones with wall perforation and hepatic abscess in the Asian subcontinent.

A retrospective study of diagnosis and management of gallbladder perforation: 10-year experience from a tertiary health care centre

Objectives

The aim of this study was to perform retrospective analysis of data collected from patients of gallbladder perforations for diagnosis, management and outcome.

Material and Methods

A retrospective analysis of data was carried out for 40 patients of gallbladder perforations from the hospital record of patients who were diagnosed preoperatively and intraoperatively as a case of gallbladder perforation over a period of 10 years and were managed in our surgery unit of a tertiary health care centre. Patients were included irrespective of sex except cases of trauma and patients of the paediatric age group.

Results

Among 40 patients, 26 were females and 14 were males. As per Anderson modification of Neimeier classification, 13 (32.5%) had type 1, 23 (57.5%) had type 2, and four (10%) patients had type 3 perforations and none of the patients had type 4 perforation. Twenty-three patients (57.5%) were found to have fundal perforation, followed by body in 11 patients (27.5%), three (7.5%) in Hartman's pouch while in three patients (7.5%), there were multiple perforations. All patients of type 1 Neimer classification were diagnosed clinically as cases of biliary peritonitis, whereas most cases of type 2 Neimer classification were diagnosed preoperatively by CECT abdomen 12/23 patients (52%) and ultrasound abdomen 10/23 (43.47%). All patients underwent surgery, and there were three mortalities.

Conclusion

In our study, there was female predominance in patients having gallbladder perforation. Of the patients, 52.5% were diabetic and mean age was 55.9 years. CECT abdomen was the most useful modality for diagnosis of type 2 gallbladder perforations. Timely surgical intervention is mandatory for a better outcome of these cases.

Detection of Gallbladder Disease Types Using Deep Learning: An Informative Medical Method

Nowadays, despite all the conducted research and the provided efforts in advancing the healthcare sector, there is a strong need to rapidly and efficiently diagnose various diseases. The complexity of some disease mechanisms on one side and the dramatic life-saving potential on the other side raise big challenges for the development of tools for the early detection and diagnosis of diseases. Deep learning (DL), an area of artificial intelligence (AI), can be an informative medical tomography method that can aid in the early diagnosis of gallbladder (GB) disease based on ultrasound images (UI). Many researchers considered the classification of only one disease of the GB. In this work, we successfully managed to apply a deep neural network (DNN)-based classification model to a rich built database in order to detect nine diseases at once and to determine the type of disease using UI. In the first step, we built a balanced database composed of 10,692 UI of the GB organ from 1782 patients. These images were carefully collected from three hospitals over roughly three years and then classified by professionals. In the second step, we preprocessed and enhanced the dataset images in order to achieve the segmentation step. Finally, we applied and then compared four DNN models to analyze and classify these images in order to detect nine GB disease types. All the models produced good results in detecting GB diseases; the best was the MobileNet model, with an accuracy of 98.35%.

Gallbladder perforation following peroral cholangioscopy-guided lithotripsy: A case report

Peroral cholangioscopy-guided lithotripsy is highly effective in clearing difficult bile duct stones. It can cause adverse events, such as cholangitis and pancreatitis; however, gallbladder perforation is extremely rare. Herein, we describe the case of a 77-year-old woman who developed gallbladder perforation following peroral cholangioscopy -guided lithotripsy. She was referred to our hospital to treat multiple large bile duct stones. She underwent peroral cholangioscopy-guided lithotripsy because of conventional lithotripsy failure. After a cholangioscope was advanced into the bile duct, saline irrigation was used for visualization. Electronic hydraulic lithotripsy was performed, but it took time for fragmentation because the calculus was hard. The 2-h endoscopic procedure did not completely remove the stone, and treatment was discontinued after placing a biliary plastic stent and nasobiliary tube. After the endoscopic procedure, she started experiencing right hypochondrial pain, which worsened the next day. Computed tomography showed a gallbladder wall defect in the gallbladder fundus with pericholecystic fluid. She was diagnosed with gallbladder perforation and underwent emergency surgery. A perforation site was found at the gallbladder fundus. Open cholecystectomy, choledochotomy, and extraction of residual bile duct stones were performed. The patient was discharged 9 days post-surgery without any complications. The saline irrigation used for visualization may have caused a surge in intra-gallbladder pressure, resulting in gallbladder perforation. Therefore, endoscopists may need to conserve irrigation water during peroral cholangioscopy-guided lithotripsy.

Clinical experience in laparoscopic treatment of gallbladder perforation

Aim

We herein present our clinical experience in laparoscopic surgery for gallbladder perforation (GBP).

Materials and Methods

Retrospective analysis was performed on the clinical data of 44 patients who diagnosed with GBP from January 2015 to November 2020.

Results

The mean age of the 44 patients was 64.0 years and the female-to-male ratio was 20:24. The most common type of GBP was Type II, followed by Type I and Type III (31:9:4). 72.7% of the patients were diagnosed with GBP at the time of surgery. Laparoscopic surgery was performed for 38 (86.4%) patients, with a conversion rate of 13.2%. The mean length of hospital stays was 7.8 days. The mortality and morbidity rates were 2.3% and 11.4%, respectively.

Conclusions

Pre-operative diagnosis of GBP is difficult. Laparoscopic surgery is safe, feasible and effective for patients with GBP.

Spontaneous Gallbladder Perforation: A Case Report

Emphysematous cholecystitis (EC) is an acute infection caused by gas-forming organisms and is considered a surgical emergency. The presenting symptoms of EC are often difficult to distinguish from those of uncomplicated acute cholecystitis, necessitating the use of CT for diagnosis. EC is associated with higher rates of gangrene and perforation of the gallbladder compared to typical acute cholecystitis. It is also associated with significantly higher rates of mortality. In this report, we discuss the case of a 57-year-old African American female who presented to the emergency room with nausea, non-bloody vomiting, and abdominal pain for three days. Physical examination showed a soft but tender abdomen, especially in the right upper quadrant, and labs showed leukocytosis of 15.5/mm³. A CT of the abdomen and pelvis was ordered, which demonstrated air in the gallbladder lumen with extraluminal air adjacent indicating ruptured EC.

Charlson Comorbidity Index as a Predictor of Difficult Cholecystectomy in Patients With Acute Cholecystitis

Background The Charlson Comorbidity Index (CCI) has been validated as a predictor of overall survival and post-surgical mortality. CCI is adopted by Tokyo Guidelines as one of the main criteria in the management of acute cholecystitis. Our study evaluates the role of CCI in predicting difficult cholecystectomy.  Methods All patients who underwent cholecystectomy for acute cholecystitis between January 2017 and September 2019 were included. CCI, Emergency Surgery Score (ESS), and American Society of Anesthesiologists (ASA) score were calculated and analyzed to assess their predictive value for difficult cholecystectomy. Results A total of 96 patients were included and allocated to difficult and non-difficult cholecystectomy groups. CCI was found to be a significant predictor of difficult cholecystectomy (OR 1.59; 59% CI, 1.04. 2.42; p= 0.031). Similarly, ESS was found to be a predictor tool of difficult cholecystectomy (OR 1.42; 59% CI, 1.05. 1.93; p= 0.024). There was no significant difference in adverse outcomes between the two groups. Conclusion CCI was able to predict a difficult cholecystectomy in our study population. However further studies are required to evaluate if it can be used as a predictor of adverse outcomes in the context of acute cholecystitis.

Spontaneous gallbladder perforation and colon fistula in hypertriglyceridemia-related severe acute pancreatitis: A case report

BACKGROUND

Gallbladder perforation and gastrointestinal fistula are rare but serious complications of severe acute pancreatitis (SAP). However, neither spontaneous gallbladder perforation nor cholecysto-colonic fistula has been reported in acalculous acute pancreatitis patients.

CASE SUMMARY

A 31-year-old male presenting with epigastric pain was diagnosed with hypertriglyceridemia-related SAP. He suffered from multiorgan failure and was able to leave the intensive care unit on day 20. Three percutaneous drainage tubes were placed for profound exudation in the peripancreatic region and left paracolic sulcus. He developed spontaneous gallbladder perforation with symptoms of fever and right upper quadrant pain 1 mo after SAP onset and was stabilized by percutaneous drainage. Peripancreatic infection appeared 1 mo later and was treated with antibiotics but without satisfactory results. Then multiple colon fistulas, including a cholecysto-colonic fistula and a descending colon fistula, emerged 3 mo after the onset of SAP. Nephroscopy-assisted peripancreatic debridement and ileostomy were carried out immediately. The fistulas achieved spontaneous closure 7 mo later, and the patient recovered after cholecystectomy and ileostomy reduction. We presume that the causes of gallbladder perforation are poor bile drainage due to external pressure, pancreatic enzyme erosion, and ischemia. The possible causes of colon fistulas are pancreatic enzymes or infected necrosis erosion, ischemia, and iatrogenic injury. According to our experience, localized gallbladder perforation can be stabilized by percutaneous drainage. Pancreatic debridement and proximal colostomy followed by cholecystectomy are feasible and valid treatment options for cholecysto-colonic fistulas.

CONCLUSION

Gallbladder perforation and cholecysto-colonic fistula should be considered in acalculous SAP patients.

Pyogenic Liver Abscess Complicating Acute Cholecystitis: Different Management Options

Acute cholecystitis, which is usually associated with gallstones is one of the most common surgical causes of emergency hospital admission and may be further complicated by mural necrosis, perforation and abscess formation. Perforation of the gallbladder is a relatively uncommon complication of acute cholecystitis (0.8–3.2% in recent reviews). The intrahepatic perforation causing a liver abscess is an extremely rare condition, anecdotally reported in the scientific literature, even in the rare types of subacute or acute perforation. Liver abscess caused by gallbladder perforation can be a life-threatening complication with a reported mortality of 5.6%. The treatment of synchronous pyogenic liver abscess and acute cholecystitis may be challenging. We reported three cases of liver abscess due to acute cholecystitis in which different therapeutical approaches were employed. The first case was treated with antibiotics and interval laparoscopic cholecystectomy; the second case was treated with emergency cholecystectomy; and the third case with percutaneous aspiration of the abscess only. The appropriate therapeutical method in these cases depends on the patient’s clinical condition, the on-site expertise that is available in the hospital, and the experience of the surgeon.

Anicteric Gallbladder Rupture with Elevated Bile Acids in Abdominal Effusion in a Dog with Cholecystitis

Anicteric gallbladder rupture has been rarely described in veterinary medicine, and, generally, it has been related to gallbladder wall necrosis secondary to gallbladder mucocele. A 5 yr old, male, neutered Labrador retriever presented for acute onset anorexia, lethargy, and vomiting. Cholecystitis was diagnosed based on the ultrasonographic findings and bactibilia, and, consequently, medical treatment was established. Despite improvement of the patient, a focal ultrasound of the hepatobiliary tract was performed 72 hr after admission for reassessment, revealing gallbladder wall thickening and abdominal effusion. Intracellular bacteria were present in nondegenerated neutrophils, and the effusion was categorized as septic exudate, compatible with septic peritonitis. Exploratory laparotomy confirmed an anicteric gallbladder rupture potentially secondary to cholecystitis and/or previous cholecystocentesis. The patient was not icteric the day of the surgery, serum bilirubin was within normal limits, abdominal fluid bilirubin concentration was below that of serum, and no bile pigment was detected; however, bile acids were significantly higher in the abdominal effusion compared with the serum concentration. This case describes an anicteric gallbladder rupture in a dog with concomitant cholecystitis and raises the question about the sensitivity of bile acid evaluation as a tool for diagnosis of gallbladder rupture and bile peritonitis in dogs.

Percutaneous Cholecystostomy: A Bridge to Less Morbidity

Percutaneous cholecystostomy (PC) is a minimally invasive procedure for decompressing gall bladder (GB) or biliary system in emergency settings, performed in patients with GB or biliary diseases who are at high risk for surgical exploration. Indications range from acute cholecystitis in seriously ill patients to overdistended GB with impending perforation to overt GB perforation. This procedure, by allowing biliary drainage, helps in controlling the infection and optimizing the patient's condition for definitive treatment in the form of elective surgery if possible, thus acting as a bridge to a definitive treatment option. In some cases, such as acute acalculous cholecystitis, it may obviate the need for surgery, and in malignant biliary obstruction, it may be used as a palliative measure to keep GB decompressed. This review article focuses on and revisits many aspects of PC including technical aspects, clinical indications, outcomes, and safety of the procedure, in addition to its role as bridge therapy versus definitive therapy versus palliative option. It includes observations based on the author's own work experience and review of the literature.

Gallbladder perforation: A single-center experience in north India and a step-up approach for management

BACKGROUND

Spontaneous gallbladder perforation (GBP) is an uncommon diagnosis. This study presented the experience of managing spontaneous GBP over nine years at a large, tertiary care university hospital in north India and investigated the outcomes and treatment strategies.

METHODS

A retrospective review of prospectively maintained digital database of consecutive patients was performed. All patients received medical and/or surgical treatment for spontaneous GBP in our department between January 2010 and June 2018.

RESULTS

We identified 151 patients (81 females and 70 males) with mean age of 53 years. Most common presenting features were pain (96.7%), fever (54.3%) and jaundice (31.1%). Most common cause was gallbladder stones (84.8%) followed by common bile duct stones (30.5%), xanthogranulomatous cholecystitis (17.9%) and malignancy (11.9%). As per Niemeier classification, 8.6% had type 1 GBP (free perforation in peritoneal cavity), 76.2% had type 2 GBP (localized perforation) and 13.2% had type 3 GBP (cholecysto-enteric fistula). About 60% of the perforations were diagnosed preoperatively. Type 1 was more common in patients with diabetes and also had the worst prognosis. Surgery was performed in 109 patients (72.2%). Seven patients (4.6%) had a postoperative morbidity of Clavien-Dindo III or higher. There were three mortalities in patients who underwent surgery.

CONCLUSIONS

High index of suspicion is required for preoperative diagnosis of GBP, especially in types 2 and 3. Laparoscopic cholecystectomy can be difficult in these patients and patients may require open or partial cholecystectomy. Early diagnosis and step-up approach for the treatment of GBP is critical.

Clinical spectrum and management outcome in gallbladder perforation-a sinister entity: Retrospective study from Sub-Himalayan region of India

Objectives

Gallbladder perforation is an infrequent entity seen among surgical patients. Rare occurrence owes to difficulty in diagnosing gallbladder perforations. The aim of the present study was to determine the optimal management strategy that may decrease the morbidity and mortality associated with this potentially life-threatening condition.

Material and Methods

This was a retrospective study from hospital health records wherein the experience of 40 consecutive patients with gallbladder rupture, either spontaneous or secondary to both benign conditions and malignancy, was noted at a tertiary care hospital over 48 months from February 2017 till January 2021. The etiology, clinical presentation, and treatment given were analysed.

Results

Out of 40 patients included, 23 were females and the majority of patients were more than 45 years of age. Twelve patients responded to intravenous antibiotics and analgesics alone while five required an ultrasound-guided pigtail catheter drainage due to non-improving clinical condition. The failure of expectant management led to a delayed laparotomy in seven patients while four patients required emergency laparotomy because of generalized peritonitis. An elective cholecystectomy was offered to 12 patients with cholecystoenteric fistulae after diagnostic laparoscopy in the same admission. Thirty-eight patients were discharged in stable condition and doing well at 30-day follow-up.

Conclusion

Gallbladder perforation is seen more commonly in acute calculous cholecystitis compared to other conditions. It is more evident when the treatment of acute calculous cholecystitis is delayed by more than 6-8 weeks. The spectrum of clinical presentation varies from mild pain and vomiting to generalized peritonitis. The patient often requires a step-up approach to control the ongoing sepsis for an improved outcome.

Improved Detection of Gallbladder Perforation Using Ultrasound Small Vessel Slow Flow "Perfusion" Imaging

Gallbladder (GB) perforation is a potentially fatal cause of acute abdomen. Higher morbidity and mortality are associated with this entity due to delayed diagnosis and treatment. Ultrasound with color/power Doppler and contrast sonography can detect wall discontinuity; however, sometimes it can be subtle or unavailable. Small vessel slow flow "perfusion" imaging allows improved microvascular perfusion detection using different filters, which result in increased spatial resolution and vessel visualization. Noncontrast perfusion imaging was of immense clinical value in the diagnosis of GB perforation in the six cases presented here. To the best of our knowledge, this is the first case report describing efficacy of noncontrast "perfusion" imaging in detection of GB perforation.

Iatrogenic gallbladder perforation during laparoscopic cholecystectomy and outcomes: a systematic review and meta-analysis

AIMS

We aimed to compare the outcomes of iatrogenic gallbladder perforation (IGP) versus no gallbladder perforation in patients undergoing laparoscopic cholecystectomy.

METHODS

A systematic review and meta-analysis was conducted in compliance with PRISMA statement standards. We searched the MEDLINE, EMBASE, CINAHL Scopus, and CENTRAL to identify eligible studies. The last search was run on 17 October 2021. The outcome of interest included surgical site infection (SSI), postoperative collection, operative time, and length of hospital stay. Random effects modelling was applied to calculate pooled outcome data. The certainty of evidence was assessed using GRADE system.

RESULTS

Analysis of 5366 patients from 11 observational studies suggested that IGP during laparoscopic cholecystectomy does not increase the risk of SSI (OR: 1.48, 95% CI 0.57-3.86, P = 0.42) and postoperative collection (RD: 0.00, 95% CI - 0.00-0.01, P = 0.41) but may result in longer operative time (MD 10.28 min, 95% CI 7.40-13.16, P < 0.00001) and length of hospital stay (MD 0.51 days, 95% CI 0.15-0.87, P = 0.005). The results remained consistent through sensitivity analyses. The quality of available evidence was judged to be moderate, and the GRADE certainty of the evidence was judged to be high.

CONCLUSIONS

The best available evidence suggests that IGP during laparoscopic cholecystectomy may not increase the risk of SSI and postoperative collection but may result in longer operative time and length of hospital stay. Whether prompt retrieval of spilled stones, adequate peritoneal irrigation, and intraoperative use of prophylactic antibiotic contribute to the above findings remains unknown.

A rare case report of enteric fever causing gallbladder perforation

Introduction and importance

Enteric fever is one of the major public health problems mainly in developing countries. Gallbladder perforation is very unusual. Enteric fever rarely causes gallbladder perforation. We report a case of gallbladder perforation due to enteric fever in an adult patient.

Case presentation

A 50-year-old female without any medical illness presented with a history of intermittent fever for two weeks and three days duration of severe abdominal pain. Upper abdominal tenderness and guarding were found in the abdominal examination. Ultrasonography showed thickening of the gallbladder wall and pericholecystic fluid collection. Magnetic resonance cholangiopancreatography revealed a distended gallbladder with sludge, diffuse wall thickening, and contained perforation with a mild amount of free fluid seen in the abdomen. With the diagnosis of type II gallbladder perforation, percutaneous ultrasonography-guided drainage was done. The culture of bile revealed positivity for Salmonella Typhi. Intra-venous antibiotic (ceftriaxone and gentamicin) was administered for 14 days. Four weeks later, cholecystectomy with peritoneal lavage was done. She was discharged on the 8th postoperative day.

Clinical discussion

Preoperative diagnosing of gallbladder perforation is challenging. The accurate treatment and precise timing of the surgery remain important. In most cases, cholecystectomy and abdominal lavage are adequate to treat gallbladder perforation.

Conclusions

Gallbladder perforation is a life-threatening surgical problem. The clinician should have a high index of awareness about this unusual surgical entity due to enteric fever and early diagnosis with prompt surgical intervention is necessary to improve patient outcomes.

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Enteric fever is one of the major public health problems mainly in developing countries.

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Gallbladder perforation is a very uncommon complication of enteric fever.

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Awareness of this rare entity due to enteric fever is important for prompt timely management for better patient outcomes.

Localized gallbladder perforation: a systematic review of treatment and prognosis

BACKGROUND

The optimal management of localized gallbladder perforation (Neimeier type II) has yet to be defined. The aim of this systematic review was to identify factors associated with improved patient outcomes.

METHODS

Systematic review of studies that described the management of Neimeier type II perforation, reported complications of the first intervention, necessity of added interventions, resolution of the pathology, and days of hospital stay were included. The search strategy was conducted in EMBASE, Mayo Journals, MEDLINE, SCOPUS, and Web of Science (December 2020) RESULTS: A total of 122 patients (53% male) from case reports, series, and cohorts were included for analysis. In total 56 (46%) and 44 (36%)patients were treated with open and laparoscopic cholecystectomy respectively. Overall risk of bias was moderate. The need for another intervention was higher in the laparoscopic group (5 vs 17, p=<0.001) as well as prevalence of complications (4 vs 16, p=<0.001), but lower for days of hospital stay (median days 5. vs 15, p = 0.008) against open cholecystectomy. Preoperative percutaneous catheter drainage did not influence outcome.

CONCLUSION

Open cholecystectomy has a lower need for further surgical procedures and postoperative complications, but a longer hospital stay. These outcomes did not vary with preoperative percutaneous drainage. The effect of timing of cholecystectomy did not influence the outcomes.

[The Impact of Lockdown during the COVID-19 Pandemic on Care for Elective Patients (C-elective Study) - Results of a Multicenter Survey]

BACKGROUND

Due to the COVID-19-related lockdown regulations, surgical clinics had to cut down elective procedures. The impact of the cancellation and postponing surgery on patients is unclear.

METHODS

All patients from six hospitals with canceled surgery during the first lockdown (03/16-04/24/2020) were asked to answer a questionnaire.

RESULTS

In total, 225 patients took part. In 88 (39.1%) patients, the disease-related complaints changed, mainly towards an increase in severity (82.6%). That was especially true for hernia patients (44.4%). In 4% of the cases, there was a complication requiring surgery in the time interval between the original date of the operation and the interview. For about a third, the cancelation of scheduled surgery caused major administrative difficulties. Most of the patients (76.3%) understood the measures taken, though 40.4% of them considered that their indication was very urgent.

DISCUSSION AND CONCLUSION

The overall complication rate was low, and patients agreed to the measures taken; however, especially hernia patients showed increasing symptoms and some acute incarcerations. It seems reasonable to monitor symptomatic patients closely, in order to prioritise them when surgical capacity is restricted.

Non-malignant gall bladder perforation: Our experience from an institution-based retrospective analysis of 25 cases

Gallbladder perforation still continues to perplex surgeons; 25 such patients diagnosed either pre- or intra-operatively and managed at our institute over the last 10 years period were analysed. Only eight were diagnosed pre-operatively, while a large majority (17) had a wrong initial working diagnosis. Symptoms and signs were variable. No blood investigation was specific. A computed tomography scan was generally better than ultrasound in detecting the perforation. All our cases were managed operatively with no mortality and a mean duration of hospital stay of 6.8 days. Most perforations were extra-hepatic (84%) and those of Niemeier's type I (52.2%). Because of its varied clinical presentation, gallbladder perforation is often an intra-operative diagnosis, but early intervention carries a good outcome.

Complications of cholecystitis: a comprehensive contemporary imaging review

Acute cholecystitis is a common cause of right upper quadrant pain in patients presenting to the emergency department. Ultrasound, computed tomography, HIDA scans, and magnetic resonance imaging are increasingly utilized to evaluate suspected cases. The prognosis of acute cholecystitis is usually excellent with timely diagnosis and management. However, complications associated with cholecystitis pose a considerable challenge to the clinician and radiologist. Complications of acute cholecystitis may result from secondary bacterial infection or mural ischemia secondary to increased intramural pressure. The recognized subtypes of complicated cholecystitis are hemorrhagic, gangrenous, and emphysematous cholecystitis, as well as gallbladder perforation. Acute acalculous cholecystitis is a form of cholecystitis that occurs as a complication of severe illness in the absence of gallstones or without gallstone-related inflammation. Complicated cholecystitis may cause significant morbidity and mortality, and early diagnosis and recognition play a pivotal role in the management and early surgical planning. As appropriate utilization of imaging resources plays an essential role in diagnosis and management, the emergency radiologist should be aware of the spectrum of complications related to cholecystitis and the characteristic imaging features. This article aims to offer a comprehensive contemporary review of clinical and cross-sectional imaging findings of complications associated with cholecystitis. In conclusion, cross-sectional imaging is pivotal in identifying the complications related to cholecystitis. Preoperative detection of this complicated cholecystitis can help the care providers and operating surgeon to be prepared for a potentially more complicated procedure and course of recovery.

False Negative Hepatobiliary Iminodiacetic Acid (HIDA) Scan in a Case of Gall Bladder Perforation

Gall bladder perforation (GBP) is a rare and life-threatening complication of acute cholecystitis that requires immediate intervention. The diagnosis itself poses a diagnostic challenge, if the patient presents after the perforation of the gall bladder, especially if the initial imaging techniques such as ultrasonogram (US), computed tomography (CT) scan, hepatobiliary iminodiacetic acid (HIDA) scan and magnetic resonance cholangiopancreatography (MRCP) are inconclusive. Subtle clues such as free fluid around gall bladder and contracted gall bladder should warrant the clinician as these might be the only clues suggestive of gall bladder perforation. Here we describe a case of GBP successfully diagnosed by peritoneal drainage and analysis and subsequently managed by endoscopic retrograde cholangiopancreatography (ERCP) and open cholecystectomy.

Gallbladder Perforation Into the Peritoneal Cavity

ABSTRACT

Gallbladder perforation is an uncommon but morbid complication of acute cholecystitis with mural ischemia and necrosis. The most common site of perforation is the fundus because of limited blood supply in this region. The Niemeier classification proposed in 1934 remains the criterion standard in grading gallbladder perforation; type 1 is acute with free perforation into the peritoneal cavity, type 2 is subacute with pericholecystic abscess, and type 3 is chronic with cholecystoenteric fistula. We report a challenging case of type 1 gallbladder perforation due to acute acalculous cholecystitis.

Acute hemorrhagic cholecystitis with gallbladder rupture and massive intra-abdominal hemorrhage

Acute hemorrhagic cholecystitis is a rare, life-threatening condition that can be further complicated by perforation of the gallbladder. We describe a patient with clinical and radiologic findings of acute cholecystitis with a gallbladder rupture and massive intra-abdominal bleeding. Our patient is a 67-year-old male who presented with an ischemic stroke and was treated with early tissue plasminogen activator. His hospital course was complicated by a fall requiring posterior spinal fusion surgery. He recovered well, but several days later developed subxiphoid and right upper quadrant pain and an episode of hemobilia and melena. A computed tomography scan revealed an inflamed, distended gallbladder with indistinct margins and a large hematoma in the gallbladder fossa extending to the right paracolic gutter. The patient also developed hemodynamic instability concerning for hemorrhagic shock. He underwent an emergent laparoscopic converted to open subtotal fenestrating cholecystectomy with abdominal washout for management of his acute hemorrhagic cholecystitis with massive intra-abdominal hemorrhage. Prompt recognition of this lethal condition in high-risk patients is crucial for optimizing patient care.

Postoperative Outcomes after Index vs Interval Cholecystectomy for Perforated Cholecystitis

BACKGROUND

Gallbladder perforation is a known morbid sequela of acute cholecystitis, yet evidence for its optimal management remains conflicting. This study compares outcomes in patients with perforated cholecystitis who underwent cholecystectomy at the time of index hospital admission with those in patients who underwent interval cholecystectomy.

STUDY DESIGN

A retrospective analysis was conducted of 654 patients from the American College of Surgeons NSQIP database who underwent cholecystectomy for perforated cholecystitis (2006-2018). Primary outcomes were 30-day postoperative major and minor morbidity, 30-day mortality, and need for prolonged hospitalization. Patient and procedure characteristics and outcomes were compared using Mann-Whitney rank sum test for continuous variables and Pearson chi-square tests for categorical variables. A subset analysis was conducted of patients matched on propensity for undergoing interval cholecystectomy.

RESULTS

The 30-day postoperative mortality rate of matched cohort patients undergoing index cholecystectomy was 7% vs 0% of patients undergoing interval cholecystectomy (p = 0.01). The 30-day minor morbidity rates were 2% for index and 8% for interval patients (p = 0.06), and the major morbidity rates were 33% for index and 14% for interval patients (p = 0.003). Of the index patients, 27% required prolonged hospitalization compared with 6% of interval patients (p < 0.001). Results showed similar trends in the unmatched analysis.

CONCLUSIONS

Patients who underwent index cholecystectomy had significantly longer postoperative hospitalizations and higher 30-day postoperative major morbidity and mortality. There were no differences in 30-day minor morbidity. Selected patients with perforated cholecystitis can benefit from operative management on an interval, rather than urgent, basis.

Early laparoscopic cholecystectomy in acute gallbladder perforation: Single-centre experience

Background:

Acute gallbladder perforation (GBP) is associated with significant mortality and morbidity. Percutaneous drainage followed by interval cholecystectomy has been the preferred management. The outcomes of early surgery, especially by laparoscopy, have not been well studied in GBP. We present our experience in early laparoscopic cholecystectomy in GBP.

Methodology:

A retrospective analysis of patients admitted with GBP between April 2014 and December 2018 was done. Clinical presentation, preoperative imaging, surgical procedure, operative findings and the outcomes in these patients were analysed. Video of the surgeries was reviewed in case of the absence of data from the case records.

Results:

Fifteen patients were treated for GBP during the study period. Eleven patients were male, and the mean age was 61 years. Fourteen patients (93.3%) had associated co-morbidities. Systemic inflammatory response syndrome, sepsis, severe sepsis and septic shock were present in 3, 3, 6 and 3 patients, respectively. The location of the collection was gallbladder fossa, pericholecystic, subhepatic and diffuse in 3, 5, 4 and 3 patients, respectively. Intraoperatively, 13 patients were detected to have perforation at the fundus of the gallbladder. Cystic duct stump was managed with clip, endoloop, suturing and external drainage in 7, 2, 5 and 1 patient, respectively. Laparoscopic cholecystectomy was completed in 12 (80%) patients. Retroinfundibular technique was used in 12 (80%) patients. There was one conversion. Two patients required endoscopic retrograde cholangiogram + bile duct stenting, and one was reexplored for cystic artery bleed. There were no mortalities. The median duration of post-operative hospital stay and drain removal was 3 (1–19) and 3 (1–6), respectively.

Conclusion:

Early laparoscopic cholecystectomy in acute GBP is feasible and can be safely performed in centres having sufficient expertise. Retroinfundibular technique of laparoscopic cholecystectomy is useful in tackling frozen Calot's triangle in GBP.

Isolated Gall Bladder Perforation in a Tertiary Care Hospital in Eastern Nepal: A Descriptive Cross-sectional Study

Introduction:

Cholelithiasisis is a common surgical problem worldwide. Gall bladder perforation is a rare life-threatening complication with considerable mortality. This study aims to find the etiology, demography, type of perforation, and outcome of gall bladder perforation.

Methods:

This descriptive cross-sectional study was done on patients above 18 years of age visiting department of surgery of B. P. Koirala Institute of Health Sciences (BPKIHS) who were diagnosed with isolated gall bladder perforation. The study was done from 1st January 2006 till 30 December 2016. Ethical approval was obtained from the Institutional Research Committee (reference number. 34/074/075). The convenient sampling method was used. Data were entered in excel sheets and analyzed.

Results:

Out of 49 patients included in the study, 28 (57.14%) were females and the commonest age group was 36 to 50 years 22 (44.9%) followed by 51 to 65 years 16 (32.6%). Most of the patients presented in emergency with pain in their abdomen. Diabetes mellitus was the commonest co-morbidity present in 10 (20.41%) patients. Operative management was done in 45 (91.84%) of the patient and conservative management in 4 (8.16%). After surgery of 45 patients, 43 (95.56%) improved and 2 (4.44%) expired. The most common type of perforation was Niemeier Type I in 21 (46.67%) followed by Type III 14 (31.11%). The most common histopathological diagnosis was acute cholecystitis 20 (44.44%).

Conclusions:

Isolated gall bladder perforation is not an uncommon complication. The most common etiological factor was acute cholecystitis with a slight female predominance. Most of the patients needed surgical intervention and they had good outcomes when diagnosed and managed on time.

Role of MSCT in the diagnosis of perforated gall bladder (a retrospective study)

Background

Although gall bladder perforation (GBP) is not common, it is considered a life-threating condition, and the possibility of occurrence in cases of acute cholecystitis must be considered. The aim of this study was to assess the role of multi-slice computed tomography (MSCT) in the assessment of GBP.

Results

It is a retrospective study including 19 patients that had GBP out of 147, there were 11 females (57.8%) and 8 males (42.1%), aged 42 to 79 year (mean age 60) presented with acute abdomen or acute cholecystitis. All patients were examined with abdominal ultrasonography and contrast-enhanced abdominal MSCT after written informed consent was obtained from the patients. This study was between January and December 2018. Patients with contraindications to contrast-enhanced computed tomography (CT) (pregnancy, acute kidney failure, or allergy to iodinated contrast agents) who underwent US only were excluded. Patients with other diagnoses, such as acute diverticulitis of the right-sided colon or acute appendicitis, were excluded. The radiological findings were evaluated such as GB distention; stones; wall thickening, enhancement, and defect; pericholecystic free fluid or collection; enhancement of liver parenchyma; and air in the wall or lumen. All CT findings are compared with the surgical results. Our results revealed that the most important and diagnostic MSCT finding in GBP is a mural defect. Nineteen patients were proved surgically to have GBP.

Conclusion

GBP is a rare but very serious condition and should be diagnosed and treated as soon as possible to decrease morbidity and mortality. The most accurate diagnostic tool is the CT, MSCT findings most specific and sensitive for the detection of GBP and its complications.

Obstructive-Type Jaundice without Bile Duct Dilatation in Generalized Peritonitis Is a Specific Sign of Spontaneous Gall Bladder Perforation

Generalized peritonitis caused by spontaneous gall bladder perforation is rare and difficult to diagnose preoperatively. The increased absorption of the spilling conjugated bile from the gall bladder by the inflamed peritoneum causes jaundice and direct hyperbilirubinemia. A 56-year-old male patient with septic generalized peritonitis and obstructive-type hyperbilirubinemia came to our hospital. The blood examination showed that total, direct, and indirect bilirubin were 6.20, 5.38, and 0.82 mg/dl. The gall bladder perforation was not detected on USG, CT scan, and MRCP. On laparotomy, we found a 0.5 cm perforation on the fundus of the gall bladder and 2500 cc of bilious fluid in the peritoneal cavity. Cholecystectomy was performed, and the patient completely recovered after the surgery. Preoperative diagnosis of spontaneous gall bladder perforation is difficult even by using ultrasonography, CT scan, and MRCP. The inflammatory reaction of the peritoneum in bile peritonitis increases the absorption of the spilled conjugated bile from the peritoneal cavity. The obstructive-type hyperbilirubinemia without dilatation of the bile duct on imaging examination was the sign of bile leakage into the peritoneal cavity. In septic condition, the preoperative diagnosis of the spontaneous gall bladder perforation is important to establish so that the surgeon can make only a minimal procedure in reducing the morbidity. Therefore, it could be concluded that the presently occurring obstructive-type jaundice without dilatation of the bile duct in the case of generalized peritonitis is a specific sign of spontaneous gall bladder perforation.